Urgent balloon aortic valvuloplasty in patients with cardiogenic shock related to severe aortic stenosis: time matters.

Aims: The aim of the study was to assess the outcomes of balloon aortic valvuloplasty (BAV) as a rescue therapy in patients with cardiogenic shock (CS) related to severe aortic stenosis (AS).
Methods and Results: Forty-four consecutive patients, n=31 with hypotensive CS (HCS) and n=13 with non-hypotensive CS (NHCS) due to acutely decompensated severe AS, from two centres were treated with urgent BAV. The composite primary endpoint was mortality or recurrent CS at one-year follow-up. These patients (77.3±8.1 years old; 75% male) had a mean EuroSCORE II of 41.6±13.7%. One-month mortality was 47%. Twelve patients (27%) had either a staged TAVR (n=10) or surgical aortic valve replacement (SAVR) (n=2) with a median delay of 79 days after BAV: n=6 (19%) in the HCS subgroup and n=6 (46%) in the NHCS population (p=0.06). At one year, the rate of composite all-cause death or recurrent CS was 75% and significantly higher in the HCS subgroup (83% vs. 53%; p=0.03). Overall one-year mortality was 70% (n=31) with a trend for a better prognosis in NHCS patients (54% vs. 77%; p=0.09). Univariate predictive factors of the primary endpoint included preoperative dose of dobutamine >5 microg/kg/min (100% vs. 57%; p=0.001) and delayed BAV >48 hrs (90% vs. 59%; p=0.01).
Conclusions: Despite the initial success of urgent BAV, morbidity and mortality of CS related to severe AS remain high and directly related to the time of the valvuloplasty. Performing BAV before or within 48 hours of starting inotropic agents appears to be key to survival.